肢体恶性黑色素瘤综合治疗进展

皮肤发病率及病死率在全球均有升高趋势,其治疗包括手术、生物、化学、放射以及内分泌治疗。手术是主要治疗手段,切除后部分原发灶的缺损需要修复与重建。高剂量的干拢素(IFN)α-2b是经美国食品与药品监督管理局批准的辅助性生物治疗手段。对于转移性病灶,化疗是主要治疗手段,单药氮烯脒胺治疗仍是标准方案。放射治疗在原发灶、区域淋巴结及转移性病灶的治疗中均有一定意义;而现尚无证据支持内分泌治疗在恶性黑色素瘤治疗中的应用价值。     

原发灶不明颈部转移性鳞癌的诊治

原发灶不明的颈部转移性癌约占头颈部恶性肿瘤的5％，可以分为转移性鳞癌和转移性腺癌，至今仍是临床诊治的一个难题。由于原发灶不明的转移性癌的临床治疗只能以治标为主，治疗效果不佳。所谓原发灶不明，其实是有原发灶，由于病灶较小、部位隐匿或位于黏膜下等原因而不易发现；且肿瘤的生物学行为又较恶劣，较早发生淋巴结转移。临床仔细寻找原发病灶尤为重要，只有找到原发病灶，标本兼治，临床治愈率才能改善。20世纪50年代初，美国纽约纪念医院的Martin教授最早提出：“2周内找不到原发病灶的颈部转移性癌，即诊断为原发灶不明的颈部转移性癌”。随着医学理念的更新，诊疗技术的进步，我们认为用时间概念来作为一个诊断标准不够科学，因此提出：“经临床仔细检查直到治疗开始前仍未发现原发病灶的颈部转移性癌，可以诊断为原发灶不明的转移性癌”。以上概念是否准确大家可以讨论，本文主要讨论原发灶不明的颈部转移性鳞癌。     

乳腺癌内分泌治疗的现状及应用策略

根据国际医学数据服务公司ＩＭＳ统计，内分泌药物在中国肿瘤药物市场所占份额仅为４％，美国为其６倍，欧洲市场高达１１５倍，即使与我国肿瘤发病谱相似的日本及台湾省也约占１２％。这说明我国内分泌治疗与发达国家及地区相比还有很大差距。在我国广大医生及乳腺癌患者心目中，内分泌治疗还只是一个无足轻重的治疗手段，在临床如何合理使用内分泌治疗还存在很多迷茫及困惑。内分泌治疗作为乳腺癌的一种重要治疗手段，有两种用途（图１）：（１）有具体病灶的治疗：如根治性手术前的新辅助治疗，复发转移后的解救治疗。（２）无具体病灶…     

脑神经胶质瘤的术后治疗

恶性星形细胞瘤可扩散至邻近或远离原发灶的脑组织，手术很难将肿瘤组织彻底切除，术后放疗的作用已较明确，化疗及生物调节剂等治疗的疗效尚不能确定。在不明显增加并发症的条件下，适形放疗等提高的局控率的方法与全脑放疗及化疗等可能控制非局部病灶垢有效配合，可能是今后发展的主要方向。     

介入治疗在转移性肿瘤综合治疗中的作用

目的探讨介入治疗在转移性肿瘤综合治疗中的作用。方法对11例转移性肿瘤的转移灶进行介入栓塞化疗，对原发灶采用手术及介入治疗等综合措施。结果11例恶性肿瘤患者生存已超过2年的占72．7％(8／11)，超过3年的占63．6％(7／11)。结论对于能采取介入栓塞治疗的转移灶，进行积极的介入治疗，同时对原发灶采取手术、放化疗及介入治疗等综合治疗措施，可明显延长病人的生存时间，提高生存质量。     

介入治疗在转移性肿瘤综合治疗中的作用

目的　探讨介入治疗在转移性肿瘤综合治疗中的作用。方法　对 11例转移性肿瘤的转移灶进行介入栓塞化疗 ,对原发灶采用手术及介入治疗等综合措施。结果　 11例恶性肿瘤患者生存已超过 2年的占 72 .7% (8/11) ,超过 3年的占 63 .6% (7/11)。结论对于能采取介入栓塞治疗的转移灶 ,进行积极的介入治疗 ,同时对原发灶采取手术、放化疗及介入治疗等综合治疗措施 ,可明显延长病人的生存时间 ,提高生存质量。     

^18F-FDG符合线路SPECT／CT显像寻找肿瘤原发灶35例应用分析

[目的]探讨^18F-氟代脱氧葡萄糖（2-deoxy-2-[F-18]fluoro-D-gluocose,FDG）符合线路SPECT／CT显像在寻找肿瘤原发灶中的价值。[方法]35例原发灶不明的转移瘤患者行^18F-FDG符合线路SPECT／CT显像寻找原发灶。[结果]21例患者符合线路SPECT／CT显像发现可疑原发灶,其中16例被其他影像学检查、活检或手术病理证实,对原发灶的检出率为45．7％（16／35例）,14例未能明确原发灶。^18F-FDG符合线路显像发现其他影像学手段未发现的新病灶13个,8例改变治疗方案。[结论]^18F-FDG符合线路SPECT／CT显像在寻找转移性肿瘤原发灶有较大的临床价值。     

脑转移性肿瘤的局部治疗

脑转移性肿瘤占脑部恶性肿瘤的多数,局部治疗是其主要治疗手段,包括全脑放疗、手术及立体定向照射。不同颅内转移灶数目、不同一般情况、不同颅外病灶控制情况的患者应个体化选择不同局部治疗方式（单用或联合等）。全文就脑转移性肿瘤局部治疗情况作一分析。     

原发灶姑息放疗对未接受原发灶手术的局部晚期或远处转移性胃癌患者远期生存影响的多中心、回顾性研究

目的 探讨原发灶姑息放疗对未接受原发灶手术的局部晚期或远处转移性胃癌患者远期生存的影响.方法 选取126例未经原发灶手术治疗的局部晚期或转移性胃癌患者,所有患者均接受三维调强放射治疗,放疗范围只包括可见的大体肿瘤,不做淋巴引流区的预防照射.总剂量为45.0～50.4 Gy,单次剂量为1.8～2.0 Gy,并同时接受至少2个周期以上含铂的双药化疗.通过Kaplan-Meier法观察患者的生存情况,采用Cox回归模型分析影响OS的相关因素.结果 中位随访35个月,中位总生存期(OS)18个月,中位无进展生存期(PFS)10个月,1、2、3年总生存率分别为57.8％、37.3％、20.6％.单因素分析结果显示,年龄、N分期、M分期、对初始化疗反应情况、体力状况(PS)评分、转移病灶个数、转移类型均可能是未接受原发灶手术的局部晚期或远处转移性胃癌患者OS的影响因素.多因素分析结果显示,N分期、M分期、对初始化疗反应情况、转移类型均是未接受原发灶手术的局部晚期或远处转移性胃癌患者OS的影响因素(P﹤0.05).分层分析显示,在转移性胃癌中,寡转移患者的OS较多发弥漫性转移的患者明显延长(HR=15.028,95％CI:7.000～32.260,P=0.000).结论 对初始化疗反应良好且为寡转移的胃癌患者,通过原发灶姑息放疗,可获得生存获益.     

乳腺癌骨转移综合治疗的初步探讨

乳腺癌骨转移随着乳腺癌发病的增加而增多 ,同时 ,由于各种治疗方法的进步 ,患者寿命的延长 ,使发生骨转移的机会也增多。骨转移疼痛的治疗对提高骨转移患者的生存质量有重要临床价值 [1]。我院 1996年 8月— 2 0 0 2年 8月采用局部放疗、化疗、内照射治疗、骨膦、内分泌及综合治疗治疗乳腺癌骨转移患者154例 ,现将结果报告如下。1　资料与方法1.1　一般资料　全组 154例均为女性 ,年龄 2 6岁～ 78岁 ,中位年龄 45岁。原发灶全部经病理证实。乳腺癌患者诊断骨转移前的治疗 :未治疗 2 2例 ,单纯手术 3 7例 ,手术 +放疗 +内分泌治疗 2 3例 ,手…     

局部晚期非小细胞肺癌同步放化疗后巩固化疗

同步放化疗已经成为不可手术切除局部晚期非小细胞肺癌( LA-NSCLC)的标准治疗模式,但最佳结合模式尚未达成共识.同步放化疗后巩固化疗模式是其中之一.至今仍没有充分的证据显示同步放化疗后巩固化疗可以有更好的生存获益,其作用还有待更多的临床试验予以验证.     

非小细胞肺癌辅助靶向治疗研究进展

辅助化疗或辅助放疗有助于提高非小细胞肺癌（NSCLC）,患者的生存期,而辅助靶向治疗的研究相对较少,作用尚不明确。文章主要就NSCLC辅助靶向治疗研究进展作一综述。     

Cost-effectiveness of adjuvant chemotherapy with uracil-tegafur for curatively resected stage III rectal cancer

Recently, the National Surgical Adjuvant Study of Colorectal Cancer in Japan, a randomised controlled trial of oral uracil-tegafur (UFT) adjuvant therapy for stage III rectal cancer, showed remarkable survival gains, compared with surgery alone. To evaluate value for money of adjuvant UFT therapy, cost-effective analysis was carried out. Cost-effectiveness analysis of adjuvant UFT therapy was carried out from a payer's perspective, compared with surgery alone. Overall survival and relapse-free survival were estimated by Kaplan-Meier method, up to 5.6 years from randomisation. Costs were estimated from trial data during observation. Quality-adjusted life-years (QALYs) were calculated using utility score from literature. Beyond observation period, they were simulated by the Boag model combined with the competing risk model. For 5.6-year observation, 10-year follow-up and over lifetime, adjuvant UFT therapy gained 0.50, 0.96 and 2.28 QALYs, and reduced costs by $2457, $1771 and $1843 per person compared with surgery alone, respectively (3% discount rate for both effect and costs). Cost-effectiveness acceptability and net monetary benefit analyses showed the robustness of these results. Economic evaluation of adjuvant UFT therapy showed that this therapy is cost saving and can be considered as a cost-effective treatment universally accepted for wide use in Japan.     

同步放化疗和新辅助化疗治疗ⅡB～ⅢB期子宫颈癌的疗效分析

目的探讨同步放化疗治疗ⅡB～ⅢB期子宫颈癌的疗效。方法将126例ⅡB～ⅢB期子宫颈癌患者随机分为同步放化疗组（治疗组）和化疗后放疗组（对照组）。对照组62例外照射加腔内治疗,当放疗剂量达到30Gy时用^192Ir腔内治疗,7．0Gy／次,1次／周。当外照射剂量达到46Gv时中间挡铅。A点剂量65～70Gy,B点剂量50—56Gy结束放疗,在放疗开始前给予顺铂（DDP）20mg静脉滴注,第1天至第5天,5-氟尿嘧啶（5-Fu）750mg静脉滴注,第1天至第5天,每28d重复。2个周期结束后开始放疗,放疗结束后继续原方案化疗2个周期,共4个周期。治疗组64例,放射治疗同对照组,在放疗开始时给予DDP20mg静脉滴注,第1天至第5天,5-Fu 750mg静脉滴注,第1天至第5天,每28d重复,共用4个周期。结果全部病例随访5年以上,随访率9414％。治疗组3、5年生存率分别为82．8％、65．6％;对照组3、5年生存率分别为67．7％、46．8％,两组差异有统计学意义（x^2=3．86,P〈0．05;x^2=5．01,P〈0．05）。两组生存曲线比较差异有统计学意义（x^2=4．26,P〈0．05）,不良反应差异无统计学意义。结论同步放化疗治疗晚期子宫颈癌疗效好,可以提高3、5年生存率。不良反应无明显增加。     

Adjuvant chemo-endocrine therapy for androgen-dependent mammary tumor in mice

Summary About 500 male DS mice grafted with androgen-dependent Shionogi carcinoma 115 (SC115) were used. When the tumor diameter reached about 20 mm (approximately 25 days after transplantation), excision of the tumor and/or castration were carried out. The injection of cyclophosphamide (80 mg/kg body weight × 3 at 7-day intervals) was started from the day after excision.In mice with excised tumor, adjuvant chemo-endocrine therapy was the most effective treatment examined; cumulative 120-day mortalities after transplantation of tumors in non-treated, adjuvant endocrine therapy, adjuvant chemotherapy and adjuvant chemo-endocrine therapy groups were 91%, 29%, 21% and 0%, respectively. Castration induced development of clusters of androgen-independent cancer cells in androgendependent SC115 tumor. In mice without tumor excision, the chemo-endocrine therapy was again the most effective treatment, though 86% of mice died by the 120th day after tumor transplantation. These findings suggest the usefulness of adjuvant chemo-endocrine therapy for achieving complete remission in hormonedependent tumors. Address for reprints: K. Matsumoto, M.D., Dept. of Pathology, Osaka University, Medical School, Kita-ku, Osaka 430, Japan.     

Twelve weeks of protracted venous infusion of fluorouracil (5-FU) is as effective as 6 months of bolus 5-FU and folinic acid as adjuvant treatment in colorectal cancer

We performed a multicentre randomised trial to compare the efficacy and toxicity of 12 weeks of 5-fluorouracil (5-FU) delivered by protracted intravenous infusion (PVI 5-FU) against the standard bolus regimen of 5-FU and folinic acid (5-FU/FA) given for 6 months as adjuvant treatment in colorectal cancer. A total of 716 patients with curatively resected Dukes' B or C colorectal cancer were randomised to 5-FU/FA (5-FU 425 mg m(-2) i.v. and FA 20 mg m(-2) i.v. bolus days 1-5 every 28 days for 6 months) or to PVI 5-FU alone (300 mg m(-2) day for 12 weeks). With a median follow-up of 19.8 months, 133 relapses and 77 deaths have been observed. Overall survival did not differ significantly (log rank P=0.764) between patients receiving 5-FU/FA and PVI 5-FU (3-year survival 83.2 vs 87.9%, respectively). Patients in the 5-FU/FA group had significantly worse relapse-free survival (RFS, log rank P=0.023) compared to those receiving PVI 5-FU (3-year RFS, 68.6 vs 80%, respectively). Grades 3-4 neutropenia, diarrhoea, stomatitis and severe alopecia were significantly less (P<0.0001) and global quality of life scores significantly better (P&<0.001) for patients in the PVI 5-FU treatment arm. In conclusion, infused 5-FU given over 12 weeks resulted in similar survival to bolus 5-FU and FA over a 6 month period, but with significantly less toxicity.     

Comparison of chemoradiation with radiation as postoperative adjuvant therapy in cervical cancer patients with intermediate-risk factors

Aims

In cervical cancer patients with intermediate-risk factors, the optimal adjuvant therapy is still controversial. We retrospectively compared the treatment outcome of chemoradiation with that of radiation.

Methods

From 1997 to 2005, 79 consecutive cervical cancer patients received postoperative adjuvant therapy indicated by intermediate-risk factors. Fifty-five women received chemoradiation and 24 women received radiation. Risk factors, recurrence-free survival (RFS), adverse events, and recurrence pattern were investigated and were compared between the chemoradiation and radiation groups. RFS was calculated by the Kaplan–Meier method and was compared by the log-rank test.

Results

Risk factors were well-balanced between the two groups. Four patients recurred in the chemoradiation group and eight patients recurred in the radiation group. RFS rate of the chemoradiation group was significantly higher than that of the radiation group (P = 0.01). Hematologic toxicity was more common in the chemoradiation group than in the radiation group (P < 0.01). However, non-hematologic toxicity was similar between the two groups and most of the patients (97%) completed postoperative adjuvant therapy. Recurrence pattern was similar between the two groups.

Conclusion

In cervical cancer patients with intermediate-risk factors, chemoradiation was well-tolerated and more effective than radiation as a postoperative adjuvant therapy.     

乳腺癌治疗进展

新辅助化疗后再手术结合放疗和（或）内分泌治疗已成为乳腺癌综合治疗的一种模式。尤其是对乳腺癌研究的深入以及新药的不断问世,新辅助内分泌治疗和生物治疗又为乳腺癌患者提供了更多的治疗途径,从而更有效地保证了保乳治疗的安全性,提高了患者的生活质量。     

胰腺癌新辅助治疗和辅助治疗

胰腺癌的新辅助治疗和辅助治疗是目前胰腺癌研究的热点问题。新辅助治疗因为缺乏前瞻性随机对照研究,目前除进行临床研究外,仍不能被推荐为标准治疗方法。根据大宗病例的临床试验研究结果,胰腺癌术后化疗可以降低死亡风险,而放疗的作用仍有待进一步研究。     

Updates in adjuvant systemic therapy for melanoma

There has been a rapid increase in adjuvant therapies approved for treatment following surgical resection of stages III/IV melanoma. We review current indications for adjuvant therapy, which currently includes a heterogenous group of stages III and IV patients with melanoma. We describe several pivotal clinical trials of systemic immune therapies, targeted immune therapies, and adjuvant vaccine strategies. Finally, we discuss the evidence for selecting the most appropriate treatment regimen(s) for the individual patient.